Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines

Abstract

Because acute cholangitis sometimes rapidly progresses to a severe form accompanied by organ dysfunction, caused by the systemic inflammatory response syndrome (SIRS) and/or sepsis, prompt diagnosis and severity assessment are necessary for appropriate management, including intensive care with organ support and urgent biliary drainage in addition to medical treatment. However, because there have been no standard criteria for the diagnosis and severity assessment of acute cholangitis, practical clinical guidelines have never been established. The aim of this part of the Tokyo Guidelines is to propose new criteria for the diagnosis and severity assessment of acute cholangitis based on a systematic review of the literature and the consensus of experts reached at the International Consensus Meeting held in Tokyo 2006. Acute cholangitis can be diagnosed if the clinical manifestations of Charcot’s triad, i.e., fever and/or chills, abdominal pain (right upper quadrant or epigastric), and jaundice are present. When not all of the components of the triad are present, then a definite diagnosis can be made if laboratory data and imaging findings supporting the evidence of inflammation and biliary obstruction are obtained. The severity of acute cholangitis can be classified into three grades, mild (grade I), moderate (grade II), and severe (grade III), on the basis of two clinical factors, the onset of organ dysfunction and the response to the initial medical treatment. “Severe (grade III)” acute cholangitis is defined as acute cholangitis accompanied by at least one new-onset organ dysfunction. “Moderate (grade II)” acute cholangitis is defined as acute cholangitis that is unaccompanied by organ dysfunction, but that does not respond to the initial medical treatment, with the clinical manifestations and/or laboratory data not improved. “Mild (grade I)” acute cholangitis is defined as acute cholangitis that responds to the initial medical treatment, with the clinical findings improved.

Bacterial Pathogens from Bile and their Antimicrobial Sensitivity Pattern in a Tertiary Care Hospital

“…Acinetobacter baumanii 1 25 In an enteric fever endemic country like India, Salmonella enterica serovar typhi and S. paratyphi A are among the major biliary pathogens. Enteric fever persists for many years after convalescence and increases the risk of hepatobiliary malignancy.…”

Acute Biliary tract infections, Diagnostic criteria and Treatment

“…A high index of suspicion is required, because serious complications such as gangrenous gallbladder and perforation frequently occur [22]. Acute or ascending cholangitis is suggested by Charcot's triad of right upper quadrant or epigastric abdominal pain, fever or chills (or both), and jaundice, reported in 50% to 70% of patients [23].The additional less frequent signs of hypotension and altered mental status, in combination with Charcot's triad, constitute Reynold's pentad, which is reportedly seen in fewer than 14% of patients with ascending cholangitis. Symptoms and signs of an inflammatory response usually are present and are reflected in the presence of fever, leukocytosis, and other markers [24].…”

Clinical and regulatory protocol for the treatment of jaundice in adults and elderly subjects: a support for the health care network and regulatory system

“…Jaundice implies different syndromic, anatomical, and etiological diagnoses whose treatment may involve different health care settings and time, thus justifying the CRP elaboration. 11,12 Theoretical Considerations Jaundice is a clinical sign characterised by yellow skin, mucosa, and sclera resulting from an increased production of bilirubin, usually over 2.5 and 3.0 mg/dl. Bilirubin is produced by the degradation of complex proteins, mainly haemoglobin, and is then metabolised in the liver by hepatocytes in a process called capture .…”

“…Moreover, these patients can be treated in a moderate complexity hospital or referred to specialised care services for adequate treatment conclusion. 11,12,20 Scenario IV…”

“…All these exams can help discriminate fulminant hepatic failure from severe cholangitis, which requires antibiotics with gram-negative coverage and an anaerobic spectrum as well as emergency endoscopic biliary decompression. 11,12,20 …”